PEDS 402 Final Exam Study Guide Pediatric Dehydration & Appendicitis

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WEEK 5
Required Readings:
Lee, D., Starr, N. B., Brady, M. A., Gaylord, N. M., Driessnack, M., & Duderstadt, K.
(2020). Burns' pediatric primary care (7th ed.). Elsevier.
 Chapter 40: Gastrointestinal Disorders
 Chapter 41: Genitourinary Disorders
 Chapter 45: Endocrine and Metabolic Disorders, pp. 952–964



DEHYDRATION
- Dehydration is the loss of water and extracellular fluid. Volume depletion or
hypovolemia (loss of extracellular fluid) and dehydration are used interchangeably.
- Dehydration is classified as:
 mild (<3% weight loss when compared with recent current weight in older
children and 5% in infants)
 moderate (6% in older children and 10% in infants)
 severe (9% or greater in older children and 15% or greater in infants)
- Depending on the cause of dehydration, water and salts (primarily sodium chloride) may
be lost in physiologic proportion or disparately, producing one of three types of
dehydration: isonatremic (isotonic), hypernatremic (hypertonic), or hyponatremic
(hypotonic). When dehydration is caused by simple diarrhea, homeostatic mechanisms
can usually maintain sodium concentrations in the serum, resulting in isonatremia. When
vomiting occurs with diarrhea and water intake is less, there is greater water loss than salt
loss, potentially resulting in hypernatremic dehydration. When there is massive stool loss
of water and salt and only water is ingested, there is a large salt loss, potentially resulting
in hyponatremia.

Clinical Findings:
- The dehydration history should assess the following:
 Mental status and thirst
 Parental concern regarding decreased tearing or urination, or depressed fontanel
in infants

Physical Examination:
- One of the most useful clinical signs of hydration is capillary refill time (CRT). Normal
CRT is less than 2 seconds. CRT, skin turgor, and tachypnea, considered together, are
most helpful in determining dehydration.
- A clinical dehydration scale (CDS) is a predictive tool regarding length of stay and need
for intravenous (IV) fluids
 The four parameters used for assessment are general appearance, eyes (sunken or
not), moistness of mucous membranes, and presence of tears.

Management:




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- Determine the degree of dehydration. If minimal, mild, or moderate, oral rehydration
solution (ORS) with 70 to 90 mEq/L sodium, 25 g/L glucose, 20 mEq/L potassium, 30
mEq/L base (in the form of citrate, acetate, or lactate) with a defined osmolarity of 240 to
300 mOsm/L is recommended.
 If severe, immediate and aggressive intervention is needed (e.g., IV fluids).
- Pediatric subcutaneous rehydration using recombinant human hyaluronidase is well
established as a method to aid absorption of subcutaneous fluids, reduces the risk for
allergic reaction, and increases absorption
- Administration of oral fluid should be in frequent, small (5 mL or less) amounts. Larger
amounts may be given as tolerated. Plain water, juices, soda, milk, and sports drinks
should be avoided, because these liquids are hyperosmolar and do not provide
appropriate replacement of sugars and electrolytes.


MODULE NOTES:

Assessing, Diagnosing, and Treating Pediatric Dehydration:

Slide 1
Dehydration
 A common problem, increase risk of diarrhea
 Infants and young children are at highest risk
 Body fluids make up 75% of an infant’s body weight
 Infants/toddlers’ high ratio of surface area to weight equals more body loss through
evaporation

Slide 2
Diarrhea
 Acute diarrhea is typically caused by viruses, like rotavirus, bacteria, and parasites
 Rotavirus is common in infants between 3 and 15 months of age
 Chronic diarrhea can be caused by antibiotic treatment of another condition, poor
absorption of starches and sugars, food allergies, laxative abuse in eating disorders,
hyperthyroidism, or irritable bowel syndrome
 In acute cases, treatment is supportive and includes fluid and electrolyte replacement
and/or antidiarrheals based on age; in chronic cases, treatment is specific to the
underlying conditions

Slide 3
Assessing dehydration
 History of present illness (HPI): quantity and frequency of fluid intake, vomiting, and/or
diarrhea, urine output or number of wet diapers in 24 hours, duration or degree of fever,
types of medications, underlying diseases
 Weight is the most essential measure in calculating body fluid loss
 Physical exam (PE): vital signs, color, capillary refill, skin turgor, dryness of lips and
mucous membranes, lack of tears, sunken fontanelles, output, and mental status




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Slide 4
Severity of dehydration (Hay et al., 2020)
Mild Moderate Severe
dehydration dehydration dehydration

Decrease in 3-5% 6-10% 11-15%
weight

Skin turgor Normal Slight tenting Severe tenting

Pulse Normal Slight increase Tachycardia

Capillary refill 2-3 seconds 3-4 seconds Greater than 4
seconds

Tears Decreased ----------------- Absent

Urine output Mild oliguria ----------------- Anuria

Slide 5
Treatment of mild to moderate dehydration (Centers for Disease Control and Prevention [CDC],
n.d.c.); Hay et al., 2020)
 Commercially available oral hydration solutions (ORS)
 Continue breastfeeding with ORS supplementation
 Offer young children 20 ml/kg per hour
 Offer older children 100 mL of ORS every 5 minutes
 Combine with IV therapy as needed
 Reassess after 4 hours; repeat if needed
 Avoid juice, soft drinks, and sports drinks

Slide 6
Treatment of severe dehydration (CDC, n.d.c.; Hay et al., 2020)
 Evidence of compromised perfusion and severe dehydration
 IV therapy of Ringer's lactate or normal saline if Ringers not available
o under 1 year, 30 ml/kg over the first hour, 70 ml/kg for the following 6 hours, and
100 ml/kg from 6 to 24 hours.
o over 1 year, 30 ml/kg over the first 30 minutes and 70 ml/kg for the following 3
hours.
o reassess every 15 to 30 minutes




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